The Assisted Suicide Juggernaut Continues in the U.S.

Since Oregon passed the first physician-assisted suicide law in 1997, 8 more states and the District of Washington, D.C. passed assisted suicide laws by 2020. They are:

  • California (End of Life Option Act; approved in 2015, in effect from 2016)
  • Colorado (End of Life Options Act; 2016)
  • District of Columbia (D.C. Death with Dignity Act; 2016/2017)
  • Hawaii (Our Care, Our Choice Act; 2018/2019)
  • Maine (Death with Dignity Act; 2019)
  • New Jersey (Aid in Dying for the Terminally Ill Act; 2019)
  • Oregon (Death with Dignity Act; 1994/1997)
  • Vermont (Patient Choice and Control at the End of Life Act; 2013)
  • Washington (Death with Dignity Act; 2008)

So far in 2021, 13 more states have new proposed assisted suicide bills and 4 states with assisted suicide laws are facing bills to expand their assisted suicide laws.

These 13 states are  Arizona , Connecticut, Indiana, Iowa, Kansas, Kentucky, Massachusetts, Minnesota, Nevada, New Mexico, New York, North Dakota and Rhode Island. Most of these states have been repeatedly hounded for years to pass an assisted suicide law.  

The 4 states with bills expanding their assisted suicide laws are California , Hawaii , Vermont, and the state of Washington.

The expansions range from expanding “qualified medical providers” from doctors to a range of non-doctors including nurses to eliminating so-called “safeguards” such as 15 day waiting periods, in person requests and even to allow electronic prescribing and shipping of lethal overdoses. Compassion and Choices (the former Hemlock Society) and other assisted suicide supporters have long portrayed assisted suicide “safeguards” as “burdensome obstacles”.

CONSCIENCE RIGHTS AND CENSORSHIP

Conscience rights for health care providers has been a very real problem since the 1974 Roe V. Wade U.S. Supreme Court decision legalized abortion in the U.S. The legalization of assisted suicide in several states has made this even worse for nurses, doctors, pharmacists and other healthcare workers. Even healthcare institutions have faced discrimination problems.

The Christian Medical and Dental Association even compiled a long list in 2019 of “Real-life examples of discrimination in healthcare” .

Now, we are seeing censorship. A March 28, 2021 Wall Street Journal op-ed titled “Big Tech Censors Religion, Too stated that:

“In January, Bishop Kevin Doran, an Irish Catholic, tweeted: “There is dignity in dying. As a priest, I am privileged to witness it often. Assisted suicide, where it is practiced, is not an expression of freedom or dignity.” Twitter removed this message and banned Bishop Doran from posting further. While the company reversed its decision after public opposition, others haven’t been so lucky.” (Emphasis added)

CONCLUSION

Back in 2014, I wrote a blog “Should a Pro-Life person Become a Nurse” about a worried pro-life student nurse who wrote me asking “what area of nursing can I move into that does not demand that I do things that I absolutely will not do?”

I wrote her back and told her that I had that challenge in several areas I worked in over 45 years but was able to live up to my ethics despite some difficult situations and that I never regretted becoming a nurse.

However, conscience rights are a not a luxury but rather a necessity.

That is why some of us nurses in Missouri worked so hard to get a conscience rights law passed in 1992 after the Nancy Cruzan starvation and dehydration death that, although not as strong as we wanted, is still in effect today. And I was thrilled when the Trump administration announced a new Conscience and Religious Freedom Division  in 2018 to enforce “federal laws that protect conscience and the free exercise of religion and prohibit coercion and discrimination in health and human services”.

Society has long insisted that health care professionals adhere to the highest standards of ethics as a form of for society. The vulnerability of a sick person and the inability of society to monitor every health care decision or action are powerful motivators to enforce such standards. For thousands of years doctors (and nurses) have embraced the Hippocratic standard that “I will give no deadly medicine to any one, nor suggest any such counsel.” Should that bright line to separate killing from caring now be erased by legislators or judges?

Without a strong resistance movement, the assisted suicide movement will only keep expanding. So far, much of the public has been shielded from the real truth by euphemisms and false reassurances from assisted suicide supporters, a mostly sympathetic mainstream media and often spineless professional and health care organizations.

We all must educate ourselves to speak out before it is too late.

A Light at the End of the (Covid 19)Tunnel?

My husband and I just returned from a trip to Florida where we were happily surprised to find the closest place to normal since the Covid 19 pandemic started. Everyone wore masks (except one young man we saw at a distance) and everyone was careful about social distancing. Hand sanitizers were everywhere.

Best of all, people seemed happy and we saw very few stores closed.

When we returned home, we both finally received the first of our 2 Covid 19 vaccination doses.

Is it possible that there is a light at the end of the Covid tunnel?

I am cautiously optimistic but aware that Covid 19 may still be a problem in the long term, especially since some younger family members-including children-contracted Covid despite precautions. Thankfully, they all had mild cases with no hospitalizations. My husband and I will continue to follow Missouri’s guidelines of masks, social distancing, etc. even after we receive our next dose of vaccine.

IS FLORIDA A HARBINGER OF GOOD NEWS?

Florida was among the last states to go into lockdown and one of the first states to ease restrictions.

Florida’s Governor Ron DeSantis was vilified by many of the media for adopting something similar to Sweden’s strategy of protecting the vulnerable while keeping businesses and schools open but a year after the pandemic hit the US, that strategy seems to be working.

Despite having the second largest number of elderly people by state, Florida’s Covid death rate numbers are better than New York’s and California’s. And, unlike so many other states, Florida’s economy is thriving.

Now, Governor Abbott of Texas and Governor Reeves of Mississippi have announced that they would be lifting their states’ mask mandates and rolling back many of their Covid-19 health mandates.

WHAT HAPPENED?

It has been almost a year since the U.S. went on lockdown for Covid 19 when President Trump declared Covid 19 a national emergency on March 13, 2020.

At first, the lockdown was only supposed to be for a few weeks to “flatten the curve” of infections and prevent hospitals from being overwhelmed by Covid patients.

However, as the lockdowns wore on for months, some doctors and other experts started warning about the emotional and health damage occurring.

Although it received little media notice, a May 19, 2020 letter to President Trump signed by over 600 doctors detailed the physical and mental impact of the lockdown in the US due to Covid 19, calling it a “mass casualty incident” with “exponentially growing negative health consequences” to millions of non-COVID patients. 

The doctors’ letter also stated that:

“Keeping schools and universities closed is incalculably detrimental for children, teenager and young adults for decades to come.”

Then on October 4, 2020, the Great Barrington Declaration was written and released and eventually signed by thousands of doctors and experts from around the world. The Declaration encouraged governments to lift lockdown restrictions on young and healthy people while focusing protection measures on the elderly, stating:

“Current lockdown policies are producing devastating effects on short and long-term public health. The results (to name a few) include lower childhood vaccination rates, worsening cardiovascular disease outcomes, fewer cancer screenings and deteriorating mental health – leading to greater excess mortality in years to come, with the working class and younger members of society carrying the heaviest burden. Keeping students out of school is a grave injustice. “

Unfortunately, Covid 19 rules and lockdowns have become a political football in many states, especially with school and small business reopenings.

CONCLUSION

We know a lot more about Covid 19 now than when the pandemic started, especially from watching U.S. states and other countries use various strategies to try to contain the virus. And now, of course, it appears we have several promising vaccines.

Although there is much more to learn, we indeed might be seeing a light at the end of the Covid 19 tunnel.

Should a Covid 19 Vaccine be Mandatory?

As the first Americans are receiving a Covid 19 vaccine, a December 5 2020 Gallup poll reports that 63% of Americans say they are willing to take the vaccine. 37% are less willing, including some groups like non-white people and Americans age 45-64. But the percentage of Americans currently willing to get vaccinated may still be below where public health experts want it.

Now, there is a proposed bill in New York to make getting the vaccine mandatory to get sufficient immunity if not enough people are voluntarily getting them.

Why are some people unwilling to get the vaccine?

As I wrote in my last blog “Ethics and the Production of Covid 19 Vaccines”, many people are concerned about the use of aborted fetal cells in some vaccines. I also included two lists of vaccines and whether or not such fetal cells were involved in their production. One list is from the Charlotte Lozier Institute and one is from the Children of God for Life organization. (The Charlotte Lozier Institute does disagree with the Children of God for Life organization on the Moderna vaccine.)

Other potential concerns are about the safety, side effects and the effectiveness of the vaccines.

EFFECTIVENESS AND SAFETY

A December 3, 2020 MedPage investigative article “Want to Know More About mRNA Before Your COVID Jab? states that “While an mRNA vaccine has never been on the market anywhere in the world, mRNA vaccines have been tested in humans before, for at least four infectious diseases: rabies, influenza, cytomegalovirus, and Zika.”

The Covid 19 vaccines use a synthetic mRNA, which is genetic information used to make the SARS-CoV-2 spike protein. When injected, the body produces a strong response to that protein to produce an immune response.

How long that response lasts is still unknown.

But, especially for certain groups of people, there are also concerns about safety.

According to the CDC (the U.S. Center for Disease Control) regarding immunocompromised patients such as those with HIV or who take immunosuppressive medications or therapies may take the vaccine but should be counseled about:

“– Unknown vaccine safety and efficacy profiles in immunocompromised persons
– Potential for reduced immune responses
– Need to continue to follow all current guidance to protect themselves against COVID-19″

Also according to the CDC, “There are no data on the safety of Covid 19 vaccines in pregnant women” but “Animal developmental and reproductive toxicity (DART) studies are ongoing” and more studies are planned.

Regarding breastfeeding, the CDC states that “There are no data on the safety of COVID-19 vaccines in lactating women or the effects of mRNA vaccines on the breastfed infant or milk production/excretion”

SIDE EFFECTS

In a Nov. 23, 2020 CNBC article “Doctors say CDC should warn people the side effects from Covid vaccine shots won’t be ‘a walk in the park, a group of doctors told the CDC to warn people that the Covid 19 vaccine shots now being rolled out may have “some rough side effects so they know what to expect and aren’t scared away from getting the second dose.”

And a December 9, 2020 article in the Wall Street Journal “Covid-19 Vaccines Pose Potential Side Effects, Doctors Say” reported that “U.K. authorities warn people with severe allergies against receiving the Pfizer-BioNTech shots, after two Britons experience allergic reactions.”

But a STAT news article a few days later on December 13, 2020, now reports that the CDC has changed its position from Persons who have had a severe allergic reaction to any vaccine or injectable therapy (intramuscular, intravenous, or subcutaneous) should not receive the Pfizer-BioNTech vaccine at this time(emphasis added) to that people who had “severe reactions to prior vaccines or injectable drugs can still get the Pfizer/BioNTech vaccine for Covid-19, but should discuss the risks with their doctors and be monitored for 30 minutes afterward”.

Another concern is that although states rely on the percentage of positive Covid 19 tests for lockdown and other orders, there are many kinds of tests and both false positive and false negative results have been reported.

No wonder many people are confused and anxious!

SHOULD COVID 19 VACCINES BE MANDATORY?

Now we are seeing Covid 19 vaccines being rapidly distributed and more Covid 19 vaccines are coming, including a Johnson and Johnson single dose Covid 19 vaccine that is in testing and the results may be known by January.

Currently, the health care workers and residents and staff of long-term care facilities have first priority for a Covid 19 vaccine.

Although states have the authority to regulate public health and they have in the past mandated vaccines for diseases like smallpox and some mandatory vaccines are required by states before children can attend school, it seems unlikely that there will be a federal mandate for the Covid 19 vaccine.

It is more likely that only certain groups of people may be required to take the vaccine like healthcare workers, universities and some employers. Even then, the Civil Rights Act of 1964 may help people who have a religious objection to a vaccine as well as anti-discrimination laws and exemptions for medical reasons. An employer would have to make a reasonable accommodation as long as it’s not too costly for the business.

It is also possible that airlines, stores, stadiums could also make vaccination a condition of doing business with a person.

CONCLUSION

The Covid 19 pandemic has taken a serious toll on everyone and we will not get back to “normal life” anytime soon, even with the Covid 19 vaccine.

But we still must make sure that any Covid 19 vaccines we take are ethical, effective and safe.

Caring for an Elderly Relative who Wants to Die

I was disturbed but not really surprised when I read the October 21, 2020 New England Journal of Medicine article by Scott D. Halpern, M.D, Ph.D., titled “Learning about End-of-Life Care from Grandpa”.

Dr. Halpern, a palliative care doctor and ethicist at the University of Pennsylvania, wrote about his elderly grandfather who had been widowed for the third time and wrote “My life was over too, only existence remained,” in a memoir for his family.

As Dr. Halpern writes, “It was downhill from there” as his grandfather coped with challenges like blindness, deafness and arthritis.

Family members offered to care for him but the grandfather chose to go into an assisted living facility where family members could visit him frequently. But then, Covid 19 visitations cut him off entirely from the outside world.

Eventually, the grandfather was allowed to see relatives one at a time outdoors at the facility.

Nearing his 103rd birthday, the grandfather started asking Dr. Halpern about “any plausible option to hasten death”.

New Jersey had recently approved physician-assisted suicide, but Dr. Halpern was “ambivalent” about that option. In addition, his grandfather did not have a terminal illness but rather was “dying of old age, frailty, and more than anything else, isolation and meaninglessness”.

Alarmingly, Dr. Halpern found that the medical code for this diagnosis called “adult failure to thrive” was being used not only used to access hospice but also to access physician-assisted suicide in some states.

Unable to find a New Jersey doctor willing to use physician-assisted suicide on his grandfather anyway, Dr. Halpern offered his grandfather the option of VSED (voluntarily stopping of eating and drinking) to hasten or cause death that the pro-assisted suicide group Compassion and Choices touts as “natural” and legal in all states.

THE TRUTH ABOUT VSED

Dr. Halpern wrote that his grandfather had trouble refusing food and water on his own. He started and stopped the process a few times.

Dr. Halpern was not surprised, writing that:

“ For people with a consistent desire to end their life, unencumbered by mental illness or immediate threats to their survival, the only alternative — to stop eating and drinking — is just too challenging. Hospice experts around the country had warned me that less than 20% of people who try to do so “succeed,” with most reversing course because of vicious thirst.” (Emphasis added)

Finally, Dr. Halpern’ write that his grandfather said “I just want it over with. Scott, do whatever you need to do.”

Dr. Halpern writes that he consulted his hospice team and began treating his grandfather’s thirst “as I treat other forms of discomfort — with morphine and lorazepam” (Emphasis added)

Even then, it took 12 long days for his grandfather to finally die.

The lessons that Dr. Halpern says he finally learned were that:

“despite many problems with physician-assisted dying, it may provide the most holistic relief possible for people who are not immediately dying, but rather are done living.”

And

stopping eating and drinking is largely impossible without knowledgeable family members and dedicated hospice care.” (All emphasis added)

CONCLUSION

Dr. Halpern obviously loved his grandfather and tried to meet his grandfather’s emotional and physical needs before telling him about the VSED option and eventually adding terminal sedation. And it seems that the imposed isolation because of potential Covid 19 infection was especially devastating for his grandfather.

But his justification for physician-assisted suicide as “the most holistic relief possible for people who are not immediately dying, but rather are done living” is chilling.

Unfortunately, that is an attitude seen all to often in medical professionals that has led to the expansion of some assisted suicide laws from terminal illness to non-terminal conditions like “completed life” and disabilities.

Both personally and professionally as a nurse, I know how difficult it can be on families when caring for a family member-especially an older relative-who says he or she wants to die.

But I also know that while we all can have sympathy for someone who says they want to die, the word “no” can be a powerful and loving response. The real answer is to help make living as good and meaningful as possible until death.

For example, I became the only caregiver when my elderly aunt developed diabetes and late-stage pancreatic cancer in 2000.

I went to doctor visits with her and went over the options with her. My aunt rejected chemo and radiation that had only a small chance of even slowing the cancer. She also refused hospice.

I offered to care for her in my home with my 15 year old daughter who also wanted to help. However my aunt felt it would cramp my daughter’s lifestyle so she decided to stay in her own home until she died.

So I helped her at home and purchased my first cell phone so that she could contact me at anytime. At that time, I was a single parent and worked full time nights in an ICU.

However, one day my aunt asked me about stopping her insulin to die faster. I told her how that could put her at risk for a heart attack or stroke from high blood sugar with no one there to help.

So she changed her mind and then even began opening up about her condition with others. She was stunned when people told her how inspiring she was and offered to help her in any way.

My aunt became happier than I had ever seen her.

Eventually, my aunt did accept hospice care at a facility she knew. I visited and called often. My aunt was physically comfortable and alert.

One day when my daughter and I went to visit her, we found that she had just died quietly in her sleep. The nurses had just stepped out to call me.

My daughter later wrote a beautiful essay about her first experience with death for her high school and received an A+. Her essay was later published on a nursing website.

In the end, causing or hastening death does not really solve anything but rather can be seen as an abandonment of the suffering person and a destroyer of the necessary trust we all must have in the ethics of our healthcare system.

We must never discriminate when it comes to helping anyone contemplating suicide.

.

Protecting Premature Babies and Abortion Survivors

On September 25, 2020, President Donald Trump signed an Executive Order on Protecting Vulnerable Newborn and Infant Children” that states:

“Every infant born alive, no matter the circumstances of his or her birth, has the same dignity and the same rights as every other individual and is entitled to the same protections under Federal law. “

This executive order came after Speaker NancyPelosi and House Democrats refused to allow a vote on the “Born Alive Abortion Survivors Protection Act” over 80 times.

ELLIOT AND EMERY

The new executive order protects not only babies who survive abortions but also those babies born prematurely like twins Emery and Elliot who were denied medical treatment after being born at 22 weeks and 5 days, despite a doctor’s prior assurances and despite the parents’ desperate pleas for treatment after the boys were born.

In an interview, the twins’ mother Amanda told me that the doctors predicted the babies would be stillborn or die shortly after birth because of their prematurity. However, the doctors were wrong: one of the boys lived for 45 minutes and the other for 2.5 hours.

Amanda and Shaun Finnefrock, the twins’ parents, have been active ever since their boys’ deaths in 2017 , advocating for “equal protection, equal treatment, the equal opportunity for survival — whether they survived an abortion or their mothers wanted them to live, like I did mine.”

They have been working on an Elliot and Emery’s Law for their home state of Ohio to protect other prematurely born babies.

Unfortunately, a 2015 University of Iowa study found that infants born at 22 weeks received potential lifesaving treatment at fewer than one in four hospitals. Almost all hospitals, the researchers found, will treat infants born at 25 weeks, but there is substantial variation among hospitals on whether they actively treat infants born at 23 or 24 weeks.

One obstacle is the fear that premature babies will be at an increased risk of disability as a result of the prematurity. But it is impossible to know at birth if the newborn will have disabilities because of prematurity. 

The good news is that studies are now finding that the majority of premature babies born at 22 weeks survive if given care.

CONCLUSION

When I started my nursing career over 50 years ago, babies more than 3 months premature routinely died because of breathing problems. But when ventilators and especially surfactant to protect the babies’ lungs were developed, “preemies” started to be saved at earlier and earlier stages with good results.

But most importantly, this progress was made because of the willingness of both parents and doctors to try to save these babies that made all the difference.

Think the Political and Cultural Divisions in Our Country are Bad? The Divisions in Medical Ethics Could Cost Your or a Loved One’s Life!

I wanted to be a nurse since I was 5. I was drawn to nursing not only because I wanted to help people but also because medical ethics standards were so high, especially in contrast to some of the corrupt business practices that I saw.

I graduated from a Catholic nursing school in 1969 and spent the next 50 years working mostly in intensive care but also in home health and hospice, oncology (cancer), kidney dialysis, volunteer work and on ethics committees.

I first noticed the change in medical ethics when the US Supreme Court’s Roe v. Wade decision in 1973 legalized abortion for the first three months of pregnancy. I was working in intensive care at the time and found that my fellow medical professionals who supported the abortion decision angrily rebuked those of us who were shocked that the first rule of medical ethics we were taught-First, Do No Harm-was eroding.

Then in 1982, my doctor husband and I were shocked by the Baby Doe case where the parents received a judge’s approval to let their newborn son with Down Syndrome die instead of repairing an easily correctable hole between the tube that leads from the throat to the stomach and the  tube that leads from the throat to the windpipe and lungs.  While lawyers were appealing his case and many parents (including my husband and me) wanted to adopt Baby Doe, the newborn starved and dehydrated to death without the desperately needed surgical repair.

My husband asked “What has happened to medical ethics??” but we both knew the answer: babies with Down Syndrome are often unwanted and aborted.

Five months after Baby Doe died, our third child Karen was born with Down Syndrome and a reparable heart defect but the heart doctor gave us a choice to “let” our baby die without surgery. We refused but my former trust in the medical system was shattered.

After I suddenly became a single parent in 1988, I had to return to a paid nursing job to support my three children but found a drastically different medical ethics system.

I found that during the 1970s, medical ethics began to evolve into the newer “bioethics”, even in Catholic hospitals.

This new bioethics has essentially four principles:

1. Respect for autonomy (the patient’s right to choose or refuse treatment)

2. Beneficence (the intent of doing good for the patient)

3. Non-maleficence (not causing harm)

4. Justice (“fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation”) Emphasis added.

Unfortunately, those principles are malleable and then used to justify actions and laws that would have been unthinkable when I graduated from nursing school. That bioethics mindset changed not only medical and nursing education but also the principles that informed our work.

Even the Hippocratic Oath, the oldest and most widely known treatise on medical ethics that forbade actions such as abortion and euthanasia that medical students routinely took upon graduation, has now been revised or dropped at many medical schools.

SOME MEDICAL ETHICS DIVISIONS THAT CAN COST YOU OR A LOVED ONE’S LIFE

Abortion

The American Medical Association, the American Congress of Obstetricians and Gynecologists and the American Nurses Association and other healthcare organization that used to condemn abortion are now supporting “abortion rights”.

Abortion on demand and taxpayer-funded has now been deemed a “civil right” by Planned Parenthood and many Democratic politicians throughout pregnancy to birth and even beyond. Alternatives to abortion such as free pregnancy tests, counseling, ultrasounds, maternity and baby clothes, diapers, car seats, bassinets, etc. are not options at Planned Parenthood but rather at non-profit crisis pregnancy centers.

As a parent of an unwed teenage daughter, I support these services and give thanks for my now 22 year old granddaughter.

Assisted suicide/euthanasia

In the early 1970s when I was a young ICU nurse, none of us medical professionals had even heard of a “living will”. There was a universal presumption for life and “quality of life” was something to be improved, not judged.

Nevertheless, sick people could and did refuse treatment and even check themselves out of the hospital against medical advice. When patients appeared to be dying, they or their families could agree to a “do not resuscitate” (DNR) order. Treatments could be ethically refused when such measures were considered medically futile or excessively burdensome for the patient. But one thing we didn’t do was offer to withhold or withdraw medical care like tube or even spoon feedings to cause or hasten a patient’s death. And it was unthinkable that medical professionals could assist even a dying patient’s suicide.

Unknown to us, all this began to change after Louis Kutner, a Chicago lawyer, wrote a 1969 article in the Indiana Law Journal titled Due Process of Euthanasia: The Living Will, A Proposal” in 1969. (emphasis added).

By 1970, The Euthanasia Society of America (later renamed the Society for the Right to Die) distributed 60,000 living wills. In 1976, California passed the nation’s first “living will” law and in 1990, The US Congress passed the Patient Self-Determination Act that requires information to be given to patients about their rights under state laws governing advance directives (commonly called “living wills), including the right to accept or refuse medical or surgical treatments.

Now, 8 states and the District of Columbia have assisted suicide laws and Compassion and Choices, the largest advocacy group for medically assisted suicide, is using the Covid 19 pandemic to push for telehealth (the provision of healthcare remotely by means of telecommunications) for medically assisted suicide.

Infanticide

In my nursing school 50 years ago, we were taught medical ethics and one example used was the case of a newborn with Down Syndrome who needed life-saving surgery but whose parents refused, choosing to let him die. We were told that the law would protect such children from medical discrimination-even by the parents.

Now we have cases like Charlie Gard and Simon Crosier and others whose parents chose life for their babies with disabilities but were thwarted by doctors and courts.

Organ donation

When I started working in an ICU in 1971, I had questions about the brain death diagnosis for organ harvesting but was told not to worry because there were strict rules.

However and over subsequent years, I discovered that the rules for organ donation have been changing from brain death to other criteria including severe brain injury. There have even been proposals for “presumed consent” state laws where people would have to register an “opt-out” or be automatically presumed to consent to organ donation.

I do not have an organ donor card nor encourage others to sign one. Instead, I once offered to give a friend one of my kidneys as a living donor. Although I was not able to donate then, my family knows that I am willing to donate tissues like corneas, bone, etc. that can be ethically donated after natural death and will only agree to that donation

Conscience rights

Doctors and nurses used to be protected when asserting their conscience rights when refusing to deliberately hastening or causing a patient’s death.

Now, even that protection-which protects both patients and medical professionals-is under attack.

I discovered this personally several years ago when I was almost fired for refusing to increase a morphine drip “until he stops breathing” on a patient who didn’t stop breathing after his ventilator was removed.

CONCLUSION

The bottom line is that everyone must remain vigilant when they or a loved one becomes seriously ill, regardless of the hospital or institution. It is also important not to be afraid to ask questions.

There are also non-denominational, non-profit groups like the National Association of Pro-life Nurses, the Healthcare Advocacy and Leadership Organization and state and national pro-life organizations that have much useful information and resources for patients, families and the public.

The bottom line is that what we don’t know-or allowed to know-can indeed hurt us. We need to demand transparency and the highest ethical standards from our doctors and healthcare system before they can earn our trust.

And without a change in laws, policies and attitudes promoting deliberate death as an answer to human suffering, those of us medical professionals who believe we should never cause or hasten anyone’s death may become an endangered species-as well as our medically vulnerable patients.

The World Brain Death Project: What It Means

THE HISTORY OF BRAIN DEATH

In December of 1967, the first successful heart transplant was performed in South Africa by Dr. Christian Barnard. At that time, there were no guidelines for the diagnosis of death for beating heart donors.

In September of 1968, the Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death was published with the purpose of defining irreversible coma as a new criterion for death.

This was done for two stated  reasons:

  1. “Improvements in resuscitative and supportive measures have led to increase efforts to save those who are desperately injured. Sometimes these efforts have only partial success so that the result is an individual  whose heart continues to beat but whose brain is irreversibly damaged. The burden is great on patients who suffer permanent loss of intellect, on their families, on the hospitals and on those in need of hospital beds already occupied by these comatose patients.
  2. “Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.” (All emphasis added)

This report was quickly accepted by many and in 1968, the Uniform Anatomical Gift Act was passed in the US  as a regulatory framework for the donation of organs, tissues and other human body parts. The Act allowed the donation of whole or part of a human body to take effect upon or after the death of the donor.

The Uniform Declaration of Death Act (UDDA) was drafted in 1981 by a President’s Commission study to brain death and approved by both the American Medical Association (AMA) and the American Bar Association (ABA). It was intended to provide a model for states to emulate.

It offered 2 definitions of when a person could be declared legally dead to align the legal definition of death with the criteria largely accepted by the medical community:

  1. “Irreversible cessation of circulatory and respiratory functions (the traditional definition of death); or
  2. Irreversible cessation of all functions of the entire brain, including the brain stem (brain death)” (Emphasis added)

The UDDA in some form has since been adopted by all US states and the District of Columbia.

However, in the June 2020 issue of the American Journal of Bioethics,  the well-known lawyer/ethicist Thaddeus  Mason Pope wrote about a current effort “to revise the Uniform Determination of Death Act (UDDA) to assure a consistent nationwide approach to consent for brain death testing.” (Emphasis added)

Why just consent to brain death testing?

According to Mr. Pope:

“Right now, a patient might be legally dead in Nevada, New York, or Virginia (where consent is not required). But that same patient might not be legally dead in California, Kansas, or Montana (where consent is required and might be refused). (Emphasis added)”

Instead, Mr. Pope proposes adding this to the Uniform Determination of Death Act (UDDA):

“Reasonable efforts should be made to notify a patient’s legally authorized decision-maker before performing a determination of death by neurologic criteria, but consent is not required to initiate such an evaluation”. (Emphasis added)

Mr. Pope states that typically, the Uniform Law Commission (ULC) follows a four-step process to change a law but notes that the Healthcare Law Committee has already skipped the first three steps and is ready for drafting the new language in the fourth step.

Ironically, there was a case last year in Michigan where the parents of a teenager  pushed for a Bobby’s Law after their son was taken off life support after being declared brain dead despite their objections. The law would “require a minor’s parents to consent to withhold or withdraw life-sustaining treatment or to give do-not-resuscitate orders before medical professionals could end life support for a juvenile” and also allow the parents to defer an apnea test (taking the person off a ventilator to see if the person is able to breathe on his or her own) required to determine brain death. (Emphasis added)

THE WORLD BRAIN DEATH PROJECT

In an August 3, 2020 article in the Journal of the American Medical Association (JAMA) titled “Determination of Brain Death/Death by Neurologic Criteria- The World Brain Death Project” , the authors state that due to “inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries”, there is a need to “formulate a consensus statement of recommendations on determination of BD/DNC”. (Emphasis added)

In a August 3, 2020 Medpage article “Brain Death: What Does It Mean?” on the World Brain Death Project, the writer notes that the “guidelines recommend that consent not be required for apnea testing because of concerns over prolonged somatic support” while quoting a doctor who disagreed:

“Ostensibly, families should be asked to provide consent because the apnea test may lead to cardiovascular collapse in some patients, classifying it as procedure with risk,” (All emphasis added)

MY JOURNEY TO DISCOVER THE FACTS ABOUT BRAIN DEATH

Back in the early 1970s when I was a young intensive care unit nurse, no one questioned the new innovation of brain death organ transplantation. We trusted the experts and the prevailing medical ethic of the utmost respect for every human life.

However, as the doctors diagnosed brain death in our unit and I cared for these patients until their organs were harvested, I started to ask questions. For example, doctors assured us that these patients would die anyway within two weeks even if the ventilator to support breathing was continued, but no studies were cited. I also asked if we were making a brain-injured patient worse by removing the ventilator for up to 10 minutes for the apnea test to see if he or she would breathe since we knew that brain cells start to die when breathing stops for more than a few minutes.

I was told that greater minds than mine had it all figured out so I shouldn’t worry.

It was years before I realized that these doctors did not have the answers themselves and that my questions were valid.

I discovered that some mothers declared “brain dead” were able to gestate their babies for weeks or months to a successful delivery before their ventilators were removed and that there were cases of “brain dead” people like Jahi McMath living for  years after a diagnosis of brain death or even recovering like Zack Dunlap

If the legal definition of brain death is truly “irreversible cessation of all functions of the entire brain, including the brain stem”, these cases would seem to be impossible.

CONCLUSION

The World Brain Death Project is riddled with potential problems in establishing a worldwide consensus on brain death criteria and testing using a “set of criteria that satisfies the lowest acceptable standard for practice”. (Emphasis added) And changing the US Uniform Determination of Death Act to supersede states requiring consent before brain death testing will not inspire trust in the healthcare system or the law.

Personally, I will not sign an organ donor card or allow my organs to be taken by donation after cardiac death (DCD), a new category of severely brain-injured people who are not brain dead but who are on ventilators (breathing machines) and considered hopeless in terms of survival or predicted “quality of life”. The ventilator is removed and the patient’s heart is expected to stop. (However, a 2016 study showed that 27% of potential donors did not die within the window specified for organ recovery.)

Instead, my family knows that I am willing to donate tissues like corneas, skin, bones, etc. that can be ethically donated after natural death.

It is vitally important that everyone understands all the facts before signing an organ donor card.

And we all should demand transparency and rigorous medical ethics from our healthcare system.

 

 

 

Palliative Care and Artificial Intelligence for Predicting Death

Working in areas like critical care, oncology (cancer) and hospice for over 45 years, I know that it is often hard to predict how long someone may live or when that person may die.

I have seen very ill or injured people with an optimistic prognosis  unfortunately die and I have seen people expected to die very soon who recovered and went on to live for years. Back then, we used pain and other specialists, social workers, ministers, etc. for all our patients when needed. Some of our patients went into hospice.

In recent years, a new specialty called palliative care was developed to improve the quality of life for patients who have a serious or life-threatening disease with the goal of preventing or treating as early as possible, the symptoms and side effects of the disease and its treatment, in addition to any related psychological, social, and spiritual problems.

So I was very interested to read a July 1, 2020 article in StatNews titled “An experiment in end-of-life care: Tapping AI’s cold calculus to nudge the most human of conversations about using cutting-edge artificial intelligence (AI) models in palliative care that scan patient hospital medical records and generate emails to doctors about their patients considered most likely to die within a year.

In the case of one doctor who received such an email,  she “was a bit surprised that the email had flagged” her patient who was in his 40s and seriously ill with a viral respiratory infection and too sick to leave the hospital. She thought “Why him? And should she heed the suggestion to have that talk?”

As the article states, those kinds of questions are increasingly cropping up among health care professionals at the handful of hospitals and  clinics around the country using such AI models in palliative care, stating that:

The tools spit out cold actuarial calculations to spur clinicians to ask seriously ill patients some of the most intimate and deeply human questions: What are your most important goals if you get sicker? What abilities are so central to your life that  you can’t imagine living without them? And if your health declines, how much are you willing to go through in exchange for the possibility of more time? (Emphasis added)

Some clinicians and researchers defend this AI by saying that doctors are “stretched too thin and lacked the training to prioritize talking with seriously ill patients about end-of-life care”.

Not surprisingly, the leaders of this palliative care AI discourage doctors from mentioning to patients that they were identified by an AI system because, as one doctor put it, ”To say a computer or a math equation has predicted that you could pass away within a year would be very, very devastating and would be really tough for patients to hear.”

Shockingly, while this AI is built around patients’ electronic health records, this article admits that some AI models also “sample from socioeconomic data and information from insurance claims.” (Emphasis added)

CAN AI RELIABLY PREDICT DEATH?

As the article admits, AI predictions of death “are often spotty when it comes to identifying the patients who actually end up dying” and that there has not been “a gold-standard study design that would compare outcomes when some clinics or patients are randomly assigned to use the AI tool, and others are randomly assigned to the usual strategies for encouraging conversations about end-of-life care.” (Emphasis added)

Nevertheless, using AI death predictions for earlier palliative care interventions is now also being tried for conditions like dementia. And last year in Great Britain, AI was touted as “better than doctors” in analyzing heart tests to determine which patients would die within a year.

ARE THERE OTHER AGENDAS?

The idea of basing medical decisions on a computer program to predict death is disturbing enough but there may be other agendas involved.

For example, in a May, 2020 Cancer journal article titled  “Leveraging Advances in Artificial Intelligence to Improve the Quality and Timing of Palliative Care”, the authors called palliative care “a discipline of increasing importance in the aging population of the industrialized nations.”  (Emphasis added

And according to a Hospice News article last year:

“Studies have found that palliative care saves health plans, health systems, and accountable care organizations close to $12,000 per person enrolled, as well as reducing hospital readmissions, emergency department visits, and hospice lengths of stay. “

Now Compassion and Choices (the former Hemlock Society) is not only fighting to legalize medically assisted suicide throughout the US, it has also been active in promoting training and expansion of palliative care with federal funding and now calls assisted suicide “one option in the palliative continuum” and that knowing assisted suicide “is an option is in itself palliative care.” (Compassion and Choices already maintains that VSED (voluntary stopping of eating and drinking) is already an ethical and legal means of ending life in the US.)

Even worse, a large and growing number of medical organizations-including the American Academy of Hospice and Palliative Medicine (AAHPM)-have endorsed or taken a neutral position on the issue of physician-assisted suicide.

CONCLUSION

An artificial intelligence program predicting death cannot replace the importance of an ethical healthcare provider who knows and truly respects the lives of his or her patients.

Good palliative care can be wonderful but, as I have written before, palliative care can go horribly wrong when misused.

We need to know the difference before we are able to trust that our own healthcare providers will  give all of us the care we need and deserve, especially at the end of our lives.

 

Covid 19 and Nursing Homes

Recently, two good friends of mine with physical limitations who had been waiting for over a year to enter a carefully chosen assisted living/long term healthcare facility changed their minds about going. They found out that the facility had at least one resident with Covid 19. They are now staying at home with help from their sons, friends and a paid caregiver.

And my 97 year old friend Melissa with heart and mobility problems is adamant about staying at home to be cared for, primarily by her wonderful family. Recently, she developed a disturbing symptom but instead of going to her doctor as usual, her doctor was able to come to her via a telehealth visit by computer. Melissa is happy at home and knows that other options like home hospice are available if necessary.

Are these three people overreacting about nursing homes?

In my opinion, the answer is probably no at this time.

Unfortunately, long-term health facilities for the elderly have become hotbeds for Covid 19 despite those residents being the most at risk during the pandemic. A number of  staff at those facilities have also caught Covid 19 and some have also died.

Even worse, as NBC News reported April 25, 2020:

“Three states hit hard by the pandemic — New York, New Jersey and California — have ordered nursing homes and other long-term care facilities to accept coronavirus patients discharged from hospitals.” (Emphasis added)

On May 6, 2020, the Wall Street Journal reported that New York nursing homes may have nearly 5,000 Covid-19 related deaths and the next day, the California Mercury News  reported that  “at least 41 percent of all known coronavirus deaths in California have occurred among residents and staff of nursing homes and assisted living facilities.” (Emphasis added)

And, unfortunately, these same people are usually dying alone due to restrictions for even family members in hospitals and nursing homes. Sadly, even funerals are changing with new restrictions for ceremonies and mourners.

According to an April 21, 2020 article “Nursing Homes Balk at COVID Patient Transfers From Hospitals” by the American Association for Retired Persons (AARP):

“The American Health Care Association says discharged hospital patients should return only to nursing homes with separate COVID-19 units. Ideally, those units are staffed with employees with access to personal protective equipment. The federal Centers for Medicare & Medicaid Services (CMS), which regulates nursing homes, endorsed the idea of separate COVID units this month.” (Emphasis added)

CONCLUSION

I was personally shocked to discover that  only  23 states publicly reported data for cases and deaths due to COVID-19 in long-term care facilities  as of April 23, 2020.

However, the Trump administration has recently announced upcoming new regulatory requirements that:

“will require nursing homes to inform residents, their families and representatives of COVID-19 cases in their facilities. In addition, as part of President Trump’s Opening Up America, CMS will now require nursing homes to report cases of COVID-19 directly to the Centers for Disease Control and Prevention (CDC).” (Emphasis added)

When my mother with Alzheimer’s disease was dying from cancer in 1988, there was no pandemic and we cared for her at home as long as possible before placing her in a nursing home nearby for safety reasons. So I do know that nursing homes and other long-term care facilities can be wonderful and even necessary options.

But until this pandemic dissipates, we need all the essential information  necessary to protect and advocate for the most vulnerable among us.

CPR (Cardiopulmonary Resuscitation) in the age of Covid 19-What You Need to Know

Several years ago, a nurse friend was with her boyfriend at a concert hall when he collapsed with no heartbeat or breathing. She called for 911, started CPR and asked for an AED (automatic external defibrillator) , which is located in most offices and public buildings. An AED is a sophisticated, yet easy-to-use (even for a lay person with training), medical device that can analyze the heart’s rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm.

However, the concert staff didn’t know where it’s AED was.

My friend continued to deliver mouth to mouth an chest compressions while a crowd gathered, some of whom were physicians who told her to stop because it was hopeless.

Finally, an ambulance arrived and took the boyfriend to a local hospital. He not only survived but was discharged 3 days later in good condition and determined to start a healthier lifestyle.

So I was stunned to read an April 21, 202 New York Post article “NY issues do-not-resuscitate guideline for cardiac patients amid coronavirus” (Covid 19) that said New York state had just issued “a drastic new guideline urging emergency services workers not to bother trying to revive anyone without a pulse when they get to a scene, amid an overload of coronavirus patients.” (Emphasis added)

While paramedics were previously told to spend up to 20 minutes trying to resuscitate a person in cardiac arrest, the new guideline was deemed “necessary during the COVID-19 response to protect the health and safety of EMS providers by limiting their exposure, conserve resources, and ensure optimal use of equipment to save the greatest number of lives.’’

First responders were outraged and their union leader said “Our job is to bring patients back to life. This guideline takes that away from us.”

Earlier this month, the Regional Emergency Services Council of New York had issued a new guideline that said cardiac arrest patients whose hearts can’t be restarted at the scene should no longer be taken to the hospital for further life-saving attempts because the city hospitals had been “inundated with dying coronavirus patients to the point where there are frequently no ICU beds.”

One paramedic acknowledged that only a small percentage of people in cardiac arrest-3 or 4 out of 100-are brought back to life through  CPR and other aggressive interventions such as drugs and hospitalization but insisted that “for those three or four people, it’s a big deal.”

On April 22 and just hours after the initial New York Post article was published, the new guidelines were rescinded. New York City’s Fire Department and first responders never adopted the no-revival directive from the state and kept using the traditional 20-minute policy.

WOULD YOU KNOW WHAT TO DO IF SOMEONE COLLAPSES WITH NO HEARTBEAT OR BREATHING?

When I started as a nurse in many decades ago, we were trained in CPR and taught how to use AMBU bags (mask, valve and self-inflating bag) to breathe for patients in arrest or distress in place of mouth to mouth resuscitation. AMBU bags are now standard equipment on ambulances and other rescue services.

Over the years, techniques for CPR changed especially in 2008 when the American Heart Association released new recommendations that bystanders can skip mouth to mouth resuscitation and use “Hands-Only CPR” to help an adult who suddenly collapses:

“In Hands-Only CPR, bystanders dial 9-1-1 and provide high-quality chest compressions by pushing hard and fast in the center of the victim’s chest.”

Now, the Covid 19 pandemic has changed CPR guidelines.

As the April 16, 2020 Notre Dame Fire Department concisely explains on pandemic-modified CPR guidelines for bystanders:

“Bystander CPR (cardiopulmonary resuscitation) improves the likelihood of an individual’s survival from cardiac arrest occurring outside of the hospital. However, coronavirus is spread through respiratory droplets when an infected person coughs, sneezes or talks. If a rescuer breathes into a cardiac arrest individual’s mouth, there will likely be an exchange of respiratory droplets. Household members who have been exposed to the individual at home should not hesitate to attempt life-saving rescue measures.

A non-household bystander who attempts to rescue a cardiac arrest individual should wear a face mask or cloth over his/her mouth and nose and place a face mask or cloth over the mouth and nose of the individual to reduce the risk of transmission.

In the case of an adult in cardiac arrest, lay rescuers should perform at least hands-only CPR. For children, lay rescuers should perform chest compressions and consider mouth-to-mouth ventilation, if willing and able, given the higher incidence of respiratory arrest in children.

To perform Hands-Only CPR, you place your hands in the center of the chest and pump hard and fast at a rate of 100 to 120 compressions per minute.

If an AED (automated external defibrillator) is available, please proceed with opening the AED and following the automated prompts to initiate life-saving intervention. Defibrillation is not expected to be a highly aerosolizing procedure. If an AED is not available, please proceed with Hands-Only CPR.

For all cardiac related emergencies, EMS (911) should be called…For more information, refer to the American Heart Association’s interim CPR guidance.

CONCLUSION

As a nurse, I have participated in many instances of cardiac or respiratory arrest and it’s always stressful. However, the joy of participating in saving someone’s life is indescribable. And even when we were unsuccessful, we had the consolation of knowing that we did everything we could for that person.

I encourage everyone to take a course to learn CPR. To find such a course, you can contact your local hospital or go to the American Heart Association’s Find A Course  or to the Red Cross website.

And I personally thank the courageous New York Fire Department and first responders for upholding the standards of care for all their patients.